Healthcare Provider Details

I. General information

NPI: 1861782898
Provider Name (Legal Business Name): N/A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 PENNSYLVANIA AVE
SAINT LOUIS MO
63133-1036
US

IV. Provider business mailing address

1318 PENNSYLVANIA AVE
PAGEDALE MO
63133-1036
US

V. Phone/Fax

Practice location:
  • Phone: 314-401-1466
  • Fax:
Mailing address:
  • Phone: 314-401-1466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number07397218
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number07397218
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number07397218
License Number StateMO

VIII. Authorized Official

Name: MS. GLORIA JEAN PATRICK
Title or Position: HOME AID
Credential:
Phone: 314-401-1466